Children suffering from autism are most often unable to collaborate to doctor during dental procedures, which results in restricted access to dental services. The application of antiepileptic drugs, associated to the main common health disorder, can provoke initiation or progression of gingival hyperplasia. The aim of our study is to investigate the interrelation between the oral health status and condition of autism in child’s age in the context of a case report. The individual dental status registration ascertains a clinical finding of totally caries-resistant mixed dentition. It concerns a patient with very good personal oral hygiene. There are no signs of clinical manifestation of gingival inflammation. We accentuate on the fact that maintenance of proper common health status and oral health, respectively high quality of life, can be provided and ensured for children suffering from autistic spectrum disorder only when parents, dental medicine doctors and physicians of different professional scopes combine their efforts and collaborate with each other.
Keywords: Oral health; Autism; Antiepileptic medicines; Child’s age
The autistic spectrum disorder (ASD) is related to disabilities of proper communication and lack of adequate social relationships . Autism is characterized as a disease of the Autism Spectrum Disorder (ASD) [2-4].
The distribution of autism is not associated to the racial traits, social-economic conditions of living and educational level of affected individuals and their families. Classic autism is related to diminished rate of language development, strict adherence to routines, hyperactivity, disability of concentration and attention [2-4].
Oral manifestations of autism are associated to clinical findings of erosion because of regurgitation, improper oral hygiene status, bruxism, tongue thrusting [2-4]. Children suffering from autism are most often unable to collaborate to doctor during dental procedures, which results in restricted access to dental services [5,6]. There is a considerable risk of seizure attacks, especially provoked during dental treatment of such patients. This is one of the most essential reasons for such children to accept antiepileptic drugs (AEDs), surgical treatment or vagus nerve stimulation . The application of antiepileptic drugs can provoke initiation or progression of gingival hyperplasia (GH) [7,8]. The state of gingival hyperplasia is related to disturbed balance and control of the growth of gingival epithelium and sub-epithelial connective tissue.
This condition of overgrowth of gingiva stimulates the process
of pathological accumulation of dental plaque, accompanied by bleeding in the region of gingival sulcus and interdental papillae. The inflammatory process hinders the procedures of maintenance of full of value oral hygiene level, leading to deterioration of oral health status [7,9-26]. These adverse effects of antiepileptic drugs’ usage can be overcome by performance of complex professional and individual oral hygiene cares. For the purposes of compensation of the negative consequences of antiepileptic drugs’ application, patients of child’s age and parents must participate in programs of prevention and educational sessions for promotion of oral health .
The current study has been performed to assess the oral health status of a child suffering from autism. We investigate the personal oral hygiene level in the role of protective factor against tooth decay and gingival inflammation. Based on scientific literature concerning various methods of evaluation of oral health in patients going through antiepileptic therapy, especially in condition of autism [27-29], we have accentuated on registration of these indicators:
a. Plaque index related to illustration of the presence of dental plaque and its quantity on teeth surfaces, corresponding to the personal oral hygiene level → namely PLI Silness-Lȍe;
b. Index of gingival inflammation regarding alteration of
gingival tissue color, presence or absence of edema and/or
bleeding → namely GI Lȍe-Silness;
c. Depth of probing, with measurement of the values
of gingival pockets at medial, central and distal areas of
vestibular and oral surfaces around each tooth;
d. Assessment of the frequency of oral hygiene procedures,
especially tooth brushing with tooth pastes appropriate to
child’s age characteristics.
On Figure 1 we illustrate the interrelations between autism
spectrum disorder, antiepileptic drugs and oral health. We
represent a clinical case of a child at the age of 5 years and 1 month
suffering from autism, with anamnestic data for epileptic seizures.
Epileptic seizures’ attacks have been controlled by acceptance of
Valproic acid-containing medicine of Convulex and Neurotop, with
the basic ingredient of Carbamazepine.
The individual dental status registration ascertains a clinical
finding of totally caries-resistant mixed dentition, with all the 20
primary upper and lower teeth unaffected by carious process.
There are no lesions of type D1a, D1b, D2, D3a, D3b, as well as D4.
We record presence of tooth 41 in pre-functional eruptive phase,
with lingual location to tooth 81 (Figure 2).
According to the value of PLI=0, 54, it concerns a patient with
very good personal oral hygiene. There are no signs of clinical
manifestation of gingival inflammation, no pathological alteration
of the color or consistency of gingival tissue, no edema, no locations
of bleeding, none anamnestic data of pain symptoms. The clinical
situation of gingival health is ascertained by the gingival index
equal to zero, GI=0. We have recorded normal depth of gingival
sulcus in the range between 0, 5 and 3mm.
Parents accentuate on the fact that they are concentrating their
efforts for ensuring adequate oral health cares for their child by
regular performance of tooth brushing procedures twice per day,
morning and evening before going to bed. The toothpastes applied
are fluoride containing, with precise dosage of fluorides according
to the age of the child. The usage of “pea size” amount of fluoride
tooth paste containing 500ppm F, as a form of exogenous fluoride
prophylaxis, provides optimal prophylactic effect for hard teeth
structures and anti-plaque accumulation effect for maintaining
healthy gingival tissues, in condition of no risk of fluorosis.
On Figure 3 we illustrate the interrelations between the oral
health status of children suffering from common health disorders
and various environmental factors.
The absence of carious lesions in the child participating in
that case report can be explained by the strict control exercised by
parents regarding the specifics of the dietary regime. The limited
consumption of sugar-containing foods and drinks only once per
day during the main meal, and not immediately before going to
bed, ensures stability of the pH level in saliva. The considerably
decreased frequency of disaccharides’ intake correlates to
minimized episodes of pH value equal to 5, 5 or lower, resulting
in irreversible demineralization of hard teeth tissues . Besides
following precisely balanced principles of alimentary prophylaxis,
parents of children with established diagnosis of autism must
concentrate their efforts on supervision of the regularity and
strictness of tooth brushing and additional oral hygiene measures
appropriate for child’s age . The individual oral hygiene
habits of the representative of that case report correspond to
the significance of regular preventive measures combined with
proper dietary habits .
Brodie et al. [32,33] devote their research on Valproic acid
as an antiepileptic drug implemented for the purpose of proper
control of various types of epilepsy. Eeg-Olofsson et al.  have
not established any negative impact of valproic acid upon the
periodontal apparatus of teeth in ten children with mixed and
permanent dentition suffering from epilepsy. Irregular reciprocity
has been ascertained between susceptibility of gingiva to valproic acid and patient’s age. Ogunbodede et al.  established
that 33.3% of patients taking only phenytoin are affected by
pathological overgrowth of gingival tissue, progressing into
gingival hyperplasia. The ratio of epileptic patients characterized
with the state of gingival hyperplasia is elevated up to 83.3
%, regarding these accepting combination of phenytoin with
phenobarbitone. Based on profound investigations the scientific
team proved that phenobarbitone has additive effect to phenytoin
upon gingival enlargement. And in condition of monotherapy
with phenobarbitone there is no clinical manifestation of gingival
hyperplasia. The researchers Gurbuz and Tan have recorded
the state of gingival hyperplasia in none of the investigated
patients taking carbamazepine, in 16% of patients accepting
phenobarbitone and in 42% of the participants into the study going
through valproic acid-based therapy . The active substances
of valproic acid and carbamazepine exercise deteriorative
influence upon neutrophils of patients resulting in disturbance
of the frequency of the process of phagocytosis. The investigation
reveals that in epileptic patients accepting combination of valproic
acid and other antiepileptic drugs the buffer capacity of saliva is
under critical levels, combined with considerable increase of the
concentration of salivary protective enzyme of lysozyme . The
enhancement of the functionality of lysozyme as a fundamental
ingredient of unstimulated saliva correlates to scientifically based
evidence represented by Smith et al.  High levels of salivary
lysozyme can be associated to lower rate of caries incidence in
primary, mixed and permanent dentition of patients going through
complex antiepileptic therapy. The caries-resistance of the child
suffering from autism with accompanying condition of epileptic
attacks, represented in our clinical case report, can be interpreted
into the context of these studies’ results.
Taking into consideration the fact that we cannot rely on full
of value collaboration of children suffering from autism during
dental procedures, there are fundamental rules to be strictly
followed related to performance of efficient therapeutic cares [2-
4] (Figure 4).
In conclusion, on Figure 5 we accentuate on the fact that
maintenance of proper common health status and oral health,
respectively high quality of life, can be provided and ensured for
children suffering from autistic spectrum disorder only when
parents, dental medicine doctors and physicians of different
professional scopes combine their efforts and collaborate with